Haryana

StateCommission

A/234/2019

STAR HEALTH AND ALLIED INSURANCE COMPANY - Complainant(s)

Versus

KRISHAN KUMAR - Opp.Party(s)

SATPAL DHAMIJA

11 Oct 2022

ORDER

STATE CONSUMER DISPUTES REDRESSAL COMMISSION HARYANA, PANCHKULA

 

                                                      First Appeal No.234 of 2019

                                                 Date of Institution: 06.03.2019

                                                          Date of final hearing:11.10.2022

Date of pronouncement: 27.12.2022

 

Star Health and Allied Insurance Company Limited, through its Branch Manager, SCO No.242, Sector-12, Opposite Mini Secretariat, Karnal through its Authorized Siugnatory, M/s. Star Health and Allied Insurance Company Limited, 2^nd Floor, 13, Alipur Road, Civil Lines, Delhi-110054, at present at Gautam Budh Nagar, Noida (U.P.).

                                                                                     ....Appellant

Versus

 

Krishan Kumar son of Shri Duli Chand, resident of Village Kurian, District Karnal.

                                                                                           ...Respondent

CORAM:    S.P. Sood, Judicial  Member

                    Suresh Chander Kaushik, Member

                   

Present:-    Mr. Satpal Dhamija, Advocate for the appellant.

                   Mr. Manoj Kumar alongwith Mr. Harish Bhardwaj, Advocate for the respondent.

 

                                                 ORDER

S P SOOD, JUDICIAL MEMBER:

          The present appeal No.234 of 2019 has been filed against the order dated 14.01.2019 of the District Consumer Disputes Redressal Forum, Karnal (In short now “District Commission”) in complaint case No.344 of 2017, which was allowed.

2.       The brief facts of the case are that the complainant had taken a Medical Term Policy alongwith his family members including his son namely Master Ankush commencing from 28.03.2017 to 27.03.2018. It was submitted that in the month of June, 2017, complainant’s son namely Master Ankush fell ill and was thus admitted in Fortis Hospital, Shalimar Bagh, New Delhi and spent an amount of Rs.3,77,803/- on his treatment. However unfortunately, Master Ankush could not recover and died on 16.06.2017 at Fortis Hospital, Shalimar Bagh, New Delhi. After the death of his son, being a nominee, complainant lodged the death claim. OP wrongly repudiated his claim vide letter dated 29.07.2017 on the false and flimsy grounds and only made the payment of medical expenses of Rs.2086/-. Thus there was clear cut deficiency in service on the part of the OP, hence this complaint.

3.      Upon notice, OP filed its written version stating therein that complainant had concealed the true and material facts, complaint is false and frivolous etc. were also raised and requested to dismiss the complaint.

          On merits, it was admitted that the complainant had availed Family Health Optima Insurance Plan covering himself, Sushila-spouse, Ms. Neeru & Mr. Ankush Joon-Dependent children for the sum Insured of Rs.5,00,000/-. The insured was admitted at Fortis Hospital on 12.06.2017 for treatment and had submitted Pre Authorization request for cashless treatment. It was further stated that MVR (Mitral Valve Replacement) of insured was done in 2013 and the same was not disclosed in the proposal form at the time of inception of the policy in question. So it was alleged that since at the time of taking of the policy, complainant had concealed the true and material facts regarding the health of insured Ankush, hence, the claim was rightly repudiated, there being no deficiency in service on the part of the OP.

4.      After hearing both the parties, the learned District Commission, Karnal has allowed the complaint vide order dated 14.01.2019, which is as under:-

“We allow the present complaint and direct the OP to pay the amount incurred by the complainant during the treatment of the insured i.e. Rs.3,77,803/- alongwith interest @ 9% per annum from the date of repudiation of the claim of complainant. We further direct the OP to pay Rs.20,000/- to the complainant on account of mental agony and harassment suffered by him and for the litigation expenses. This order shall be complied within 30 days from the receipt of copy of this order.”

5.      Feeling aggrieved therefrom, OP-appellant has preferred this appeal before this Commission.

6.      This arguments have been advanced by Sh. Satpal Dhamija, learned counsel for the appellant as well as Sh. Manoj Kumar alongwith Mr. Harish Bhardwaj, learned counsel for the respondent. With their kind assistance the entire record of appeal as well as original record of the District Commission including whatever evidence has been led on behalf of  both the parties has also been properly perused and examined.

7.      It is not disputed that the complainant had purchased a Family Health Optima Insurance Plan covering Mr. Krishan Kumar-Self, Sheela-Spouse, Miss Neeru and Mr. Ankush Joon-Dependent children for a sum assured of Rs.5,00,000/- from the opposite party.  It is also not disputed that during the subsistence of the policy in question, one of the insured was hospitalised for treatment. The claim was repudiated by the opposite party only for the reason that MVR (Mitral Valve Replacement) of insured was replaced in the year 2013 and the insured has categorically concealed this fact and did not disclose the same at the time of inception of policy. But there is no record on the file to prove that the insured died due to MVR, which was done in the year 2013.The OP has produced treatment record of Master Ankush Joon from Fortis Hospital, Shalimar Bagh, New Delhi but failed to draw our attention the record/opinion of the concerned doctor regarding case of death to show any iproximity between death and that of MVR, which was done in the year 2013.  The case law relied upon by counsel for the respondent titled  Gurbax Singh & Anr. Vs. Star Health & Allied Insurance company ltd. & Ors Law finder Doc Id # 1110537 is relevant and applicable in the case in hand because the facts and circumstances of the case is similar. The repudiation of the claim was bad in the eyes of law and was not justified. The OP has illegally repudiated the claim of the complainant. The learned District Commission has rightly allowed the claim of the complainant. The learned District Commission had committed no illegality while passing the order dated 14.01.2019.  The appeal is also devoid of merits and stands dismissed.

8.      The statutory amount of Rs.25,000/- deposited at the time of filing the appeal be refunded to the complainant-respondent against proper receipt and identification in accordance with rules, after the expiry of period of appeal/revision, if any.

9.                Applications pending, if any stand disposed of in terms of the aforesaid order.

10.              A copy of this order be provided to all the parties free of cost as mandated by the Consumer Protection Act, 1986/2019. The order be uploaded forthwith on the website of the commission for the perusal of the parties.

11.              File be consigned to record room after due compliance.

 

27th  December, 2022       Suresh Chander Kaushik            S. P. Sood                                                                Member                                             Judicial Member                            

S.K(Pvt. Secy.)